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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 126801871
Report Date: 11/21/2023
Date Signed: 11/21/2023 09:31:32 AM


Document Has Been Signed on 11/21/2023 09:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ALDER BAY ASSISTED LIVINGFACILITY NUMBER:
126801871
ADMINISTRATOR:ANDERSON, SARAFACILITY TYPE:
740
ADDRESS:1355 MYRTLETELEPHONE:
(707) 444-8000
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:49CENSUS: 28DATE:
11/21/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Sara AndersonTIME COMPLETED:
09:45 AM
NARRATIVE
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At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct a Case Management/Legal/Non-compliance visit. LPA met with Executive Director Sara Anderson and reviewed the areas of concern addressed in the Non-Compliance plan.
Building Maintenance: Facility did not ensure resident rooms were heated to at least 68 degrees Fahrenheit: LPA observed the temperature in the building was 71 degrees F in resident occupied areas.
Injections: Facility staff gave an injection while not being a skilled professional: All medication staff have been trained on injections and medication management.
Staffing: Facility did not have sufficient dietary staff to ensure resident dining needs were met. Facility did not have sufficient care giving staff to ensure residents needs were met. Residents did not receive showers on scheduled days and resident laundry was not being washed in a timely manner: Facility has hired additional positions for the kitchen and has filled all level of care positions to ensure the resident needs are being met.
Activities: Facility did not have an activities program for residents. Activities Director has been hired. Facility has a printed monthly activities calendar that is updated with input from Resident council. Activities are being conducted daily.

During this inspection, LPA followed up on an unusual incident report submitted to CCL on 11/14/2023, in regards to a medication error where Resident, R1, received another residents, R2, medication. LPA reviewed resident records and staff training records. Staff member responsible has received additional training to ensure errors do not continue.
Continued on LIC809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ALDER BAY ASSISTED LIVING
FACILITY NUMBER: 126801871
VISIT DATE: 11/21/2023
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Director will forward copies of completed staff training to LPA.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Sara Anderson and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/21/2023 09:31 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ALDER BAY ASSISTED LIVING
FACILITY NUMBER: 126801871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2023
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care,(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records reviewed,
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Licensee conducted retraining for medication staff. POC Cleared at time of visit.
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Licensee did not ensure resident received medication as ordered. This poses an immediate Health and Safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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